Nutritional status plays an important role in cancer treatment. Several studies have strongly indicated that malnutrition has a negative impact on the efficacy of cancer treatment. Nutritional negligence or poor nutrition may impede the progress in cancer care, rendering them a harder time with the toxic side effects. It is well documented that there is a high prevalence of cancer-related malnutrition ranging from 25% to 70% from various studies, and cancer patients are the most malnourished of all other patient groups. Escalation of nutrients, effective counseling, and consistent monitoring as an adjuvant to cancer treatment, not only improve nutrition parameters, and body composition but also help in managing toxic effects, thus enhancing the quality of life and ultimately better survival.
Cancer is one of the leading cause of mortality worldwide.
Cancer cachexia resulting from metabolic alterations, systemic inflammation and decreased appetite, is characterized by an involuntary sustained weight loss and loss of skeletal muscle mass, with or without loss of fat mass, and is irreversible by conventional nutritional support.
More than 50% of patients experience chemotherapy-associated dysgeusia, nausea, vomiting and mucositis, and complications of radiotherapy (RT) are also fairly common. It is also established that poor nutritional status increases surgical morbidity and post-surgical complications.
The aim of nutritional intervention is to identify, prevent and treat malnutrition through nutritional counseling. Available data and guidelines clearly indicate that nutritional intervention should be central and adjuvant to any treatment.
This panel discussion was part of an event sponsored by “Nutri Health Foundation” The panel was comprised of authors of this summary who are nutrition experts. The panel discussion was chaired and moderated by Author 1. A literature search with specific terms related to cancer and nutrition was done. Each area of nutritional management was discussed at length.
Screening for nutritional status should be done during the first visit to the hospital for outpatient consultation and within 24 hours (or) at the earliest opportunity for inpatients as it helps identify patients at risk of becoming malnourished.
Screening should be done by consulting doctors or the outpatient department (OPD) nurse in the outpatient setting or by trained RMO/ health care professionals.
Patients found to be at risk should be referred to the Clinical Nutrition Therapist for comprehensive nutritional assessment.
Nutritional assessment should be repeated during the course of treatment.
Subjective Global Assessment (SGA) and Patient Generated-Subjective Global Assessment (PG-SGA- For literate population) are validated tools for nutritional assessment of adult oncology patients.
SGA should be complemented with Biochemical parameters.
Imaging techniques help detect loss of muscle mass and fatty infiltration.
More simple assessment tools can be included such as handgrip strength assessment, gait- speed test and nutrition focused physical examination.
Nutritional assessment should be performed for the stages of cachexia, as nutritional intervention is most effective in the stages of pre-cachexia.
Nutritional assessment can include inflammatory markers such C-reactive protein, serum albumin, hyperglycemia and symptoms such as anorexia.
Patients’ medical history, age, type and stage of cancer, and response to treatment, determine nutritional intervention.
For Patients who can eat and have a functional gastrointestinal tract, nutritional counseling, with or without oral nutritional supplement (ONS) should be the foremost intervention.
Nutritional counselling is the first priority to improve nutrition intake. In case of inadequacy, ONS should be recommended.
If oral nutrition is not possible or is inadequate, artificial nutrition should be considered.
Choice of enteral nutrition (EN) or parenteral nutrition (PN) must take into account the extent of GUT availability, the amount of oral food intake, tolerance, symptoms, tumor site, its extent and complications, treatment plan and intent, prognosis, and patient’s overall physical status and the duration of the nutritional support.
EN should be preferred in patients with preserved GI functions in order to maintain gut integrity, reduce bacterial translocation and to reduce infectious complications.
In radiation-induced severe mucositis or in obstructive tumors of the head-neck, thorax and upper GI either PEG (percutaneous endoscopic gastrostomy) or nasogastric tube are recommended.
If EN is insufficient, a combination of EN and PN or PN alone should be considered. PN should be initiated early whenever indicated.
In case of GI failure, macronutrient and micronutrient’ requirements can only be fulfilled via the parenteral route long term artificial nutrition as home parenteral nutrition (HPN) is the standard recommendation.
Refeeding Syndrome (RS) prevention is recommended when BMI is <16kg/m2 or in the presence of unintentional weight loss of >15% within the last 3 to 6 months or whenever there is little or no nutritional intake for more than 2 to 3 days or if there are decreased levels of potassium, phosphorus, thiamine or magnesium prior to feeding.
Enhanced recovery after surgery (ERAS) program is recommended for all cancer patients undergoing curative or palliative surgery.
Screening for and providing additional nutritional support if necessary.
Avoidance of preoperative fasting, preoperative carbohydrate treatment and the re- establishment of oral feeding on the first postoperative day should be considered.
Patients not at risk of aspiration, and patients with normal bowel movements must be encouraged to eat solid food until 6 hours and drink clear fluids until 2 hours before anaesthesia.
In patients at nutritional risk, nutritional support for 7 to 14 days before surgery, if not at least for 5 days is recommended.
An early start of nutritional supplementation when required can significantly diminish the degree of weight loss and incidence of complications.
If oral intake is possible, start after surgery without interruption. If not possible, EN should be initiated within 24 hours.
Oral mucositis, dysphagia, odynophagia, and diarrhea are common complications of cancer treatment.
Nutritional counseling is recommended during radiotherapy, especially in head and neck, thorax and upper GI cancers.
ONS, and/or artificial nutrition should be considered in presence of severe mucositis or obstructive tumours of the head and neck or thorax.
In patients who are undergoing cancer treatment, PN should only be considered when adequate nutrition cannot be assured with orally and/or EN.
The following specific nutrients have been established to have a positive impact on the disease process.
The recommended protein intake is 1.2–1.5 g/kg/day.
Amino acid supplementations have been tested in cancer, further research is needed to clarify potential benefits.
Lack of good quality protein during cancer treatment can lead to sarcopenia, and associated complications, and impact Qol and survival.
Whey protein isolate (WPI) supplementation has been reported to benefit the nutritional status and immunity parameters, QoL, functional status, and muscle strength.
WPI supplementation can improve protein synthesis, due to their faster digestion, leading to a more rapid increase in plasma amino acid levels, particularly in essential amino acids.
Intervention studies have shown that protein supplementation with exercise/ physical activities improves muscle mass and function among sarcopenic older adults, and preserves muscle mass during intentional weight loss in obese older adults.
Whey Protein also contain high levels of other essential amino acids, such as leucine, which makes them an important food source for sustaining muscle protein anabolism and function.
EPA supplementation inhibits catabolic stimuli by checking the production of pro-inflammatory cytokines and enhancing insulin sensitivity leading to protein synthesis.
EPA improves calorie and protein intake, reduces inflammation, and can modulate body composition.
Studies suggest n−3 fatty acids can inhibit cancer cell proliferation and decrease Chemotherapy (CT) toxicity without significant side effects.
Micronutrient supplementation can be considered in severely malnourished patients with inadequate food intake even after nutritional intervention with (or) without ONS and in conditions where micronutrient deficiency is established through investigations.
Micronutrient supplementation is recommended in all patients receiving TPN.
Nutrition plays a pivotal role in all phases of cancer management even during survivorship.
All cancer patients must be screened by a validated screening tool. Identified malnourished individuals would further undergo comprehensive nutritional assessment (including lab parameters and nutrition focused physical examination) and repeated as and when required.
Patient specific nutrition intervention can improve body composition and treatment’s efficacy, with the likelihood of tolerance and improving prognosis of the disease itself.
The opinion experessed in this article are purely of authors and the journal of nutrition research neither endorses nor reject these opinions.